Optical pupillometry in traumatic brain injury: neurological pupil index and its relationship with intracranial pressure through significant event analysis.

Primary Objective: Treatment paradigms for traumatic brain injury (TBI) rely on invasive monitoring of intracranial pressure (ICP) for planning intervention. Optical pupillometry is a non-invasive, objective monitoring method, measuring parameters of pupillary response and displaying a scalar value - a neurological pupil index (NPi). An impaired response on NPi has been tentatively correlated with ICP, through analysis of mean/peak NPi and ICP readings. We sought to evaluate this relationship more closely. Research Design: Prospective observational. Methods and Procedures: We obtained hourly pupillometry readings, alongside ICP values, from 40 patients with TBI requiring invasive ICP monitoring. Significant events were identified for analysis based on the significant aberration of ICP or NPi. Main Outcomes and Results: On average, individuals experienced a few significant events. There was a weak relationship between ICP events and a preceding NPi event. The results show that there is a weak but statistically insignificant relationship between NPi and ICP, where reduced pupil reactivity may indicate a raised ICP. The strength of this trend appears to diminish post-decompressive surgery. Conclusions: Whilst pupillometry may not be a reliable surrogate marker for ICP, NPi may still prove to be a useful tool in a multimodal prognostic assessment of the patient with acute brain injury.

How do oral and maxillofacial surgeons manage concussion?

Craniofacial trauma results in distracting injuries that are easy to see, and as oral and maxillofacial surgeons (OMFS) we gravitate towards injuries that can be seen and are treatable surgically. However, we do tend not to involve ourselves (and may potentially overlook) injuries that are not obvious either visually or radiographically, and concussion is one such. We reviewed the records of 500 consecutive patients who presented with facial fractures at the Queen Elizabeth Hospital, Birmingham, to identify whether patients had been screened for concussion, and how they had been managed. Of the 500 cases 186 (37%) had concussion, and 174 (35%) had a more severe traumatic brain injury. The maxillofacial team documented loss of consciousness in 314 (63%) and pupillary reactions in 215 (43%). Ninety-three (19%) were referred for a neurosurgical opinion, although most of these were patients who presented with a Glasgow coma scale (GCS) of ≤13. Only 37 patients (7%) were referred to the traumatic brain injury clinic. Recent reports have indicated that 15% of all patients diagnosed with concussion have symptoms that persist for longer than two weeks. These can have far-reaching effects on recovery, and have an appreciable effect on the psychosocial aspects of the patients' lives. As we have found, over one third of patients with craniofacial trauma are concussed. We think, therefore, that all patients who have been referred to OMFS with craniofacial trauma should be screened for concussion on admission, and at the OMFS follow up clinic. In addition, there should be an agreement between consultants that such patients should be referred to the traumatic brain injury clinic for follow up.

Decompressive craniectomy and cranioplasty: experience and outcomes in deployed UK military personnel.

OBJECT: In recent conflicts, many UK personnel sustained head injuries requiring damage-control surgery and aeromedical transfer to the UK. This study aims to examine indications, complications and outcomes of UK military casualties undergoing craniectomy and cranioplasty from conflicts in Afghanistan and Iraq. METHODS: The UK military Joint Theatre Trauma Registry (JTTR) was searched for all UK survivors in Afghanistan and Iraq between 2004 and 2014 requiring craniectomy and cranioplasty resulting from trauma. RESULTS: Fourteen decompressive craniectomies and cranioplasties were performed with blast and gunshot wounds equally responsible for head injury. Ten survivors (71%) had an Injury Severity Score (ISS) of 75, normally designated as 'unsurvivable'. Most were operated on the day of injury. Seventy-one percent received a reverse question mark incision and 7% received a bicoronal incision. Seventy-nine percent had bone flaps discarded. Overall infection rate was 43%. Acinetobacter spp was the causative organism in 50% of cases. Median Glasgow Outcome Scale (GOS) at final follow-up was 4. All casualties had a GOS score greater than 3. CONCLUSIONS: Timely neurosurgical intervention is imperative for military personnel given high survival rates in those sustaining what are designated 'un-survivable' injuries. Early decompression facilitates safe aeromedical evacuation of casualties. Excellent outcomes validate the UK military trauma system and the stepwise performance gains throughout recent conflicts however trauma registers most evolving to have specific relevance to military casualties. In high-energy trauma with contamination and soft-tissue destruction, surgery should be conducted with regard for future soft tissue reconstruction. Bone flaps should be discarded and cranioplasty performed according to local preference. Facilities receiving military casualties should have specialist microbiological input mindful of the difficulties treating unusual microbes.

[Overweight (obesity) from the psychiatric viewpoint and its relevance for general practice]. / Ubergewicht (Adipositas) aus psychiatrischer Sicht und seine Relevanz für die allgemeinärztliche Praxis.

Obesity is of great importance for health and health economy. It often goes along with immense subjective and objective suffering. It has traditionally been a topic of general and internal medicine. This article summarizes results derived from recent psychiatric and psychotherapeutic approaches, that may also be of interest for the somatic physician as they contribute to the understanding and therapeutic management of the disease. Common definitions of obesity and epidemiologic data are presented. Traditional therapeutic approaches such as reducing diets often turned out to be insufficient. New knowledge, especially on ponderal and nutritional physiology (set point theory of body weight, investigations of dietary effects), studies about comorbidity with disturbed eating habits (particularly binge eating and bulimia) and about psychodynamics and life quality are expected to contribute to a better understanding of this phenomenon.